Flexor Tendon Injuries

Brian Miller, MD
Leif Sigurdson, MD, FRCSC
 Flexor Tendon Injuries
• Restoration of satisfactory digital function
after flexor tendon lacerations remains one
of the most challenging problems in hand
surgery
• Prior to the 1960’s tendons lacerated in
“no man’s land” were not repaired in favor
of delayed grafting
 Flexor Tendon Injuries
• Kleinert and Verdan (1960’s) showed
superior results with primary repair leading
to general acceptance of this approach
• Years of anecdotal experience and
surgical dogma followed pertaining to
repair techniques and postoperative
management
 Flexor Tendon Injuries
• In the past 25 years more scientifically
sound research has advanced our
understanding of flexor tendon structure,
nutrition, healing, biomechanics, response
to stress, repair techniques
• Many studies have examined passive and
active motion protocols
• Greatest limiting factor: absence of a
universal system for assessing outcome
 Flexor Tendon Injuries
• Questions
– Primary repair vs delayed grafting?
– Repair of FDS and FDP vs FDP alone?
– Flexor sheath excision? repair? neither?
– Type of suture material?
– Repair technique?
– Benefit of postoperative motion? Active or
passive? How much?
 Tendon Morphology
• 70% collagen (Type I)
• Extracellular components
– Elastin
– Mucopolysaccharides (enhance water-binding
capability)
• Endotenon – around collagen bundles
• Epitenon – covers surface of tendon
• Paratenon – visceral/parietal adventitia
surrounding tendons in hand
• Synovial like fluid environment
 Anatomy
• Extrinsic flexors
– Superficial group
• PT, FCR, FCU, PL
• Arise from medial
epicondyle, MCL,
coronoid process
 Anatomy
• Extrinsic Flexors
– Intermediate group
• FDS
• Arises from medial
epicondyle, UCL,
coronoid process
• Usually have independent
musculotendinous origins
and act independantly
 Anatomy
• Extrinsic flexors
– Deep group
• FPL – originates from
entire medial third of
volar radius
• FDP – originates on
proximal two thirds of the
ulna, often has common
musculotendinous origins
 Anatomy
• Carpal
tunnel
– 9 tendons
– Median
nerve
 Anatomy
• Flexor sheaths
• approx distal palmar
crease
– Predictable annular
pulley arrangement
• Protective housing
• Gliding surface
• Biomechanical
advantage
• Synovial layers
merge at MP
level
• Flexor tendons
weakly attached to
sheath by vinculae
 Anatomy
• Camper’s Chiasma
 Tendon Nutrition
• Vascular
– Longitudinal vessels
• Enter in palm
• Enter at proximal synovial fold
– Segmental branches from digital arteries
• Long and short vinculae
– Vessels at osseous insertions
• Synovial fluid diffusion
– Imbibition (pumping mechanism)
 Tendon Nutrition
• Dorsal vascularity
• Avascular zones
– FDS (over proximal
phalanx
– FDP (over middle phalanx)
• Nutrition vital for rapid
healing, minimization of
adhesion and restoration
of gliding
 Biomechanics
• Effeciency of flexor system = the degree to
which tendon excursion and muscle
contraction translates into joint motion
• Governed by integrity of the pulley system
and resistance to glide
– A2 and A4 most significant
• Pulleys decrease the moment arm length
at each joint leading to increased joint
motion
Biomechanics
 Tendon Healing
• Inflammatory phase (0-5 d); fibroblastic
phase (5d – 6wks); remodelling (6wks-
9mos)
• Intrinsic vs extrinsic healing
• Balance between the two determines
amount of extrinsic adhesion vs intrinsic
tendon healing
 Tendon Healing
• Factors affecting tendon healing, and
adhesion formation
– Surgical technique
• decreased vascularity
• gapping
– Postoperative motion (passive, active)
 Tendon Adhesion
• Increased adhesion formation with:
– Traumatic/surgical injury
• Crush injuries
– Ischemia
• Disruption of vinculae
– Immobilization
– Gapping at repair site
– Excision/injury to flexor sheath components
• Debate over benefit of sheath repair
 Tendon Adhesion
• Experimental attempts to minimize
adhesion formation
– Oral: steroids, antihistamines, NSAIDS
– Topical: beta-aminoproprionitrile,
hydrocyprolins, hyaluronic acid, collagen
solutions, fibrin
– Physical: silicone/cellophane wrapping,
polyethylene tubes, interposed sheath flaps
• Varying lab success but none proven
definitively or adopted into clinical practice
 Tendon Healing
• “It now seems irrefutable that the most
effective method of returning strength and
excursion to repaired tendons involves the
use of strong, gap resistant suture
techniques followed by the frquent
application of controlled motion stress”
-Strickland
 Diagnosis
• History
 Diagnosis
• History
 Diagnosis
• Physical exam
• Abnormal resting posture
• Absent FDP / FDS function
• Associated digital nerve and digital vessel
injury

• Discuss nature of injury and postoperative

course with patient
 Zones of Injury

FDS Insertion

Flexor Sheath
(proximal)
TCL
(distal edge) Carpal Tunnel
 Flexor Tendon Repair
Timing

• Delayed equal or better than emergent

repair
– Acute or subacute acceptable
– Tendon deterioration/shortening after several
wks
– Delay several days if wound infected
 Incisions
• Factors
– Avoid crossing joints
at 90 deg.
– Preference
– Existing lacerations
– Need to expose other
structures
 Tendon Retrieval
• Avoid trauma to synovial sheath lining
• Forcep/hemostat/skin hook if proximal
stump visible
• Proximal to distal milking, reverse
esmarch
• Suction catheter
• Suture catheter to proximal tendons in
palm and deliver distally
 Tendon Retrieval
- Retraction often limited to A1/A2 pulley
region by vinculae
- If lacerated proximal to vinculae or if
vinculae disrupted, tendon ends may
retract into plam
- If proximal stumps have retracted into the
palm the correct orientation of FDS and
FDP must be re-established (such that
FDP lies volar to Camper’s Chiasm)
 Repair Techniques
• Ideal
– Gap resistant
– Strong enough to tolerate forces generated by
early controlled active motion protocols
• 10-50% decrease in repair strength from day 5-21
post repair in immobilized tendons
• This is effect is minimized (possibly eliminated)
through application of early motion stress
– Uncomplicated
– Minimal bulk
– Minimal interference with tendon vascularity
 Core Sutures
• Current literature supports several conclusions
regarding core sutures
– Strength proportional to number of strands
– Locking loops increase strength but may collapse and
lead to gapping
– Knots should be outside repair site
– Increased suture callibre = increases strength
– Braided 3-0 or 4-0 probably best suture material
– Dorsally placed suture stronger and biomechanically
advantageous
– Equal tension across all strands
 Dorsal vs Volar
– Historically dorsal placement avoided due to
tendon vascular anatomy
– Diffusion now felt to be primary source of
nutrition during healing
– Biomechanical advantage and increased
tensile strength found during finger flexion
with dorsal sutures (Komanduri, Soejima,
Stein)
– Increase work of flexion with volar sutures
(Aoki)
 Locking vs Grasping Loops

– Locking stronger, and greater gap resistance

in two stranded repairs (Manske et al.)
– Dorsal vs volar placement did not affect
strength with locking repairs, but did affect
strength of grasping repairs (Stein)
 Cross-Sectional Area
– Increasing the cross-sectional area of the
locking loop from 10 to 50% proportionately
increased the ultimate tensile strength of the
repair (Hatanaka, Manske)
• Has been demonstrated with core and
circumferential suture tecniques
 Circumferential Sutures
– Initially were designed to improve tendon
glide
– Have been shown to add tensile strength (by
10–50%) and gap resistance to repairs (Diao,
Pruitt, Silverskiold, Wade)
• Also confirmed in cyclic loading studies
– Running locked, horizontal mattress,
epitenon/intrafibre, and cross-stitch have
been shown to be the strongest
 Gap Formation
• Gapping at tendon repair site associated
with increased adhesion formation in
laboratory/histological analysis (Lindsay)
• Gapping > 3mm correlated with decreased
tensile strength in canine model
(Gelberman)
• Gapping > 2mm correlated with poorer
clinical results (Seradge)
 Ultimate Strength and Repair
Technique
• Proportional to number of strands
– 6 and 8 strand repairs strongest
• Steep learning curve
• Increased bulk and resistance to glide
• Increased tendon handling and adhesion formation
• May not be necessary for forces of early active
motion
– Several four strand repairs appear to have
adequate strength without complexity of 6 and
8 strand repairs
Kessler
Modified Kessler
(1 suture)
Kessler-Tajima
(2 sutures)
Cruciate 4 Strand Repair

The ideal repair?

- Strickland

- McLarney
 Strength vs Force
(Core suture with running epitendinous suture)

• Some 2-strand
repairs
vulnerable
during 1-3 wks
post repair with
light active
motion
 Suture Knot Location
• In – interference with healing at repair site
• Out – interference with tendon gliding
• Knots outside superior in one in vitro study
(Aoki)
• Statistically significant increase in tensile
strength at 6 wks with knots-inside
technique in canine model (Pruitt)
• Few studies
• No consensus
 Suture Material/Size
– Historically stainless steel (strongest and least
reactive) but difficult to work with
– Braided synthetics now most common
(ethibond, ticron, mersilene)
– Increased caliber felt to increase tensile
strength
– 2-0 or 3-0 recommended with early active
motion protocols as many 4-0 suture strength
are less than the fatigue strength of many 2
and 4 strand repairs
 Repair Augmentation
– Augmenting repairs with tendon splints or
mesh has been associated with concerns
related to decreased tendon glide and
increased adhesion formation due to foreign
body reaction
– Has not been accepted in clinical practice
 Sheath Repair
• Advantages
– Barrier to extrinsic adhesion formation
– More rapid return of synovial nutrition
• Disadvantages
– Technically difficult
– Increased foreign material at repair site
– May narrow sheathand restrict glide
• Presently, no clear cut advantage to
sheath repair has been established
 Partial Lacerations
• Controversy in past as partial lacerations
were felt to predispose to entrapment,
triggering and rupture
• Repair if > 50%
• Some advocate repair of partial
lacerations > 60%
 Tendon Advancement
– Previously advocated for zone 1 repairs, as
moving the repair site out of the sheath was
felt to decrease adhesion formation
– Disadvantages
• Shortening of flexor system
• Contracture
• Quadregia effect
• Little excursion distally, therefore adhesions near
insertion less of an issue
Tendon Excursion
 Summary
• Strong gap resistant repair
• 4 strand, locking epitendinous (or
equivalent), 3-0 suture needed for early
active motion
– 4-0 suture, modified Kessler, running
epitendinous suture adequate for more
conservative protocols
• No sheath repair
• Large grasping/locking loops
Rehabilitation
 Rehabilitation
• Early post-repair motion stress
– Shown to increase recovery of tensile
strength, decrease adhesions in multiple
animal models
– Load at failure for mobilized tendons twice
that for immobilized tendons at 3 wks
(Gelberman)
 Rehabilitation
– Application of early motion in small amounts is
felt by most surgeons to biologically alter the
process of scar formation and maturation at
the repair site such that collagen is laid down
parallel to the axial forces (increase strength),
and tendon adhesions are stretched
(increased tendon glide)
 Rehabilitation
• Mayer (1916)
– The operation should never be undertaken
unless the surgeon himself can perform
effective postoperative care
– Early motion should be instituted at the right
time
– graded exercises should be used with
corrective splints
 Rehabilitation
• Bunnel (1918)
– Postoperative immobilization
– Active motion beginning at 3 wks postop.
– Suboptimal results by today’s standards
• Improved suture material/technique as well as
postoperative rehabilitation protocols
 Rehabilitation
• Kleinert (1950s)
– Posterior splint, wrist in flexion
– Rubber bands from fingernails to volar wrist
area hold fingers in flexion
– Patient able to actively extend against rubber
bands (within confines of splint)
– Fingers pulled passively back into flexion
– Used widely since with some modifications
– Showed superior results with primary repair vs
delayed grafting
 Rehabilitation
• Tendon excursion
– MP motion = no flexor tendon excursion
– 1.5 mm of excursion per 10 degrees of joint
motion for DIP (FDP) and PIP (FDS, FDP)
– These values decrease after repair by approx.
65% (DIP motion) and 10% (PIP motion)
 Rehabilitation
• Splints
– Improved excursion with “palmar bar”
modification of Kleinert splint
– Improved differential FDS/FDP excursion with
Mayo clinic “synergistic” dynamic tenodesis
splint
– Improved excursion with wrist extension (45
degrees)
– MP’s at 90 degrees, IP’s in extension when at
rest
– Decreased tension at repair with wrist
extension (45o)and MP flexion (90o)
Rehabilitation
 Rehabilitation
– Distal palmar bar
modification of
Kleinert type splint
 Mobilization Protocols
• Active extension with rubber band flexion
– Eg. Kleinert splint, usually modified with wrist
extension, MP flexion (90 degrees) and
palmar bar to improve digital flexion
• Controlled passive motion
– Posterior splint applied post-op
– Controlled passive motion at regular intervals
 Mobilization Protocols
• Controlled active motion
– Proponents believe that excursion with
passive protocols is generally poor compared
to that achieved with light active motion
• Therefore fewer adhesions and improved outcome
– Risk: tendon rupture
• Published rupture rates similar to those with
passive protocols
– 4 and 6 strand repairs with strong
epitendinous suture
– Wrist extension and MP flexion
 Mobilization Protocols
• Many studies have described various
protocols for early protected passive and
active motion
• Results are almost always superior to
previous more conservative protocols
 FDP Avulsions
• Commonly male athletes
• Forced extension at DIP during maximal
flexion (jersey finger)
• Often missed due to normal xray and
intact flexion at MP and PIP
– Opportunity for FDP reinsertion lost if
treatment delayed
 FDP Avulsions

Leddy
and
Packer
 FDP Avulsions
- Type 1: zig-zag exposure
- Tendon delivered through
pulley system with catheter
passed retrograde
- Fixed to base of phalanx
with monofilament suture
through distal phalanx and
nail plate and tied over
button
- Fix within 7-10 days before
tendon degeneration and
myostatic shortening
occurs
 FDP Avulsions
- Type 2: small bony
fragment retracts to
A3 level
- Can fix up to 6 wks
post injury (less
shortening)
- May convert to type 1
if tendon slips through
A3 pulley and into
palm
- Use same technique
as for type 1
 FDP Avulsions
- Type 3: large bony
fragment retracts to
A4 level
- Bony reduction and
fixation of fragment
 Children
• Usually not able to reliably participate in
rehabilitation programs
• No benefit to early mobilization in patients
under 16 years
• Immobilization > 4 wks may lead to poorer
outcomes
Reconstruction
 Single Stage Tendon Grafting
Zone 2

• Indications
– Delayed treatment making end to end repair
impossible
• Patient factors prevent repair
• Late referral, missed tendon laceration or avulsion
– Supple joints with adequate passive ROM
 Single Stage Tendon Grafting
Zone 2

• Technique
– 1 cm distal FDP stump left intact
– 1 cm of FDS insertion left intact (decreased
adhesion formation vs granulating insertion
site)
– Tenodesis of FDS tail to flexor sheath (10-20
deg of flexion) optional
• Hyperextension at PIP in absence of FDS tendon
occurs occasionally
 Single Stage Tendon Grafting
Zone 2

• Technique
– Graft donors
• Palmaris longus
• Plantaris
• Long toe extensors
• (FDS)
• (EIP)
• (EDM)
 Single Stage Tendon Grafting
Zone 2

• Technique
– Graft passed through pulley system
• Atraumatic technique
– Distal fixation with tension set proximally or
proximal fixation first
– Multiple methods for fixation of graft ends
 Single Stage Tendon Grafting
Zone 2

• Technique
– Distal
juncture
 Single Stage Tendon Grafting
Zone 2

• Technique
– proximal
juncture

Pulvertaft weave creates a

stronger repair vs end to end
techniques, and allows for
greater ease when setting
tension
 Single Stage Tendon Grafting
Zone 2

• Setting tension
– GA
• With wrist neutral
• Fingers fall into semi flexed position (slightly less
than ulnar neighbour), allowing estimation of
tension
– Local anesthesia, active flexion
– Electrical stimulation
• Bunnel – “tendons shrink”
• Pulvertaft – “tendons stretch”
 Secondary Reconstruction
Zone 1

• Zone 1 (functioning FDS)

– Eg. Late presentation of FDP avulsion
– DIP fusion
– Tendon graft
• Risks damaging FDS function through
injury/adhesions in a very functional finger
• ? Young patients, supple joints, need for active
DIP flexion
 Secondary Reconstruction
Zones 3, 4 and 5

• Usually associated with 3 – 5 cm gap

– Interposition graft
– FDS to FDP transfer
– End to side profundus juncture
 Two Stage Reconstruction
• Primary grafting likely to give poor result,
but salvage of functioning finger still
desirable
• Sub-optimal conditions
– Extensive soft tissue scarring
• Crush injuries
• Associated fractures, nerve injuries
– Loss of significant portion of pulley system
 Two Stage Reconstruction
• Patient selection
– Motivated
– Absence of neurovascular injury
– Good passive joint motion
• Balance benefits of two additional
procedures in an already traumatized digit
with amputation/arthrodesis
 Two Stage Reconstruction
• Stage 1
– Excision of tendon remnants
• Distal 1 cm of FDP left intact, remainder excised to
lumbrical level
• FDS tail preserved for potential pulley
reconstruction
– Incision proximal to wrist
• FDS removed/excised
• Hunter rod then placed through pulley system and
fixed distally (suture or plate and screw –
depending on implant)
 Two Stage Reconstruction
• Stage 1
– Rod extends proximally to distal forearm in
plane between FDS and FDP
– Test glide
– Reconstruct pulleys as needed if implant
bowstrings
 Two Stage Reconstruction
• Stage 1
– Postop
• Start passive motion at 7 days
• Continue x 3mos to allow pseodosheath to form
around implant
• Before stage 2 joints should be supple, and
wounds soft
 Two Stage Reconstruction
• Stage 2 – implant removal and tendon
graft insertion
– Distal and proximal incisions opened
– Implant located proximally and motor selected
(FDP middle/ring/small, FDP index)
– Graft harvested, sutured to proximal implant
and delivered distally
• Fixed to distal phalanx with pull out wire over
button
 Two Stage Reconstruction
• Stage 2 – implant removal and tendon
graft insertion
– Proximally sutured to motor with pulvertaft
weave
• FDS transfer from adjacent digit described
• Obviates need for graft
• Difficulty with length/tension
• Postop
• Early controlled motion x 3 wks, then slow
progression to active motion
 Pulley Reconstruction
• Pulley loss
– Bowstringing = tendon taking shortest
distance between remaining pulleys
– Biomechanical disadvantage
• Excursion translates into less joint motion
– Adhesions/rupture at remaining pulleys due to
increased stress
– A2 and A4 needed (minimum)
• Most biomechanically important
• Some authors advocate reconstructing a 3 or 4
pulley system for optimal results
 Pulley Reconstruction
• Most done in conjunction with a two stage
tendon reconstruction
• Can be done with single stage tendon
graft
• generally if extensive pulley reconstruction
is required it is better to do a two stage
procedure
 Pulley Reconstruction
• Methods
– Superficialis tendon
• Insertion left intact
• Remnant sutured to original pulley rim, to
periosteum, or to bone through drill holes
– Tendon graft
• Sutured as above
• Passed through hole drilled in phalanx (risk of
fracture)
• Wrapped around phalanx (requires 6-8 cm of graft)
Pulley Reconstruction
 Pulley Reconstruction
• Methods
– Extensor retinaculum
• Excellent gliding surface
• Difficult to harvest the 8-6 cm required for fixation
around phalanx
– Artificial materials
• Dacron, PTFE, nylon silicone
• Due to abundant atogenous material and
disadvantages of artificial materials, this has not
become common clinical practice
• May be stronger in long term vs autogenous
 Tenolysis
– Release of nongliding adhesions for salvage
in poorly functioning digits with previous
tendon injury
– Avoid in marginal digits
• May not tolerate additional vascular/neurologic
injury
– May need concomitant collateral ligament
release, capsulotomy
– Prepare patient for possible staged
reconstruction
 Tenolysis
• Timing
– 3-6 mos. Post repair (minimum)
– Plateau with physiotherapy
• Anesthesia
– Local with sedation
• Allows patient participation
• Tests adequacy of release
• Motivates patient
 Tenolysis
• Technique
– Zig zag incisions
– Adhesions divided maintaining non-limiting
adhesions
– Pulleys reconstructed as needed
• If extensive or not possible convert to staged
reconstruction
– Immediate motion postop.